Report of Illness

**Please note: You must be following standard company policy by calling in to the restaurant 651-222-5670 and by submitting this form at least 3 hours prior to your scheduled shift.  We need to opportunity to cover the shift and have the PTO request approved and processed. Thank you.**

Name *
Name
Date *
Date
(Please describe your symptoms of illness)
What is your scheduled in-time?
What is your scheduled in-time?
For multiple date requests, meaning that you are anticipating being out with illness, injury, health related issue or need to take a leave for more than one day, please type all dates/shifts here (your PTO will be determined based upon your balance and annual allowance):
Please enter amount of hours you would like to use of your PTO for this shift/request?

All "Report of Illness" submissions will be sent to management and evaluated for approval.  
Once approval is granted the hours will be submitted to payroll for benefits.  
Your submission will be logged in our company "sick log" and tracked for health & HR purposes.  

We truly hope you feel better and are able to return to work soon.